Airway Management in Transport

Toni Petrillo-Albarano, MD Pediatric Critical Care Medicine Childrens Healthcare of Atlanta at Egleston Childrens Hospital

Objectives
Overview

of the differences between the pediatric and adult airway Intubation of the pediatric patient

Anatomic Considerations in Pediatrics

Relatively

Large Occiput Large Tongue Larynx is anterior and superior Epiglottis may be floppy with acute angle Narrowest portion is cricoid cartilage

The Basics
The airway in any patient can be: Physiologic
maintained easily or with effort by the patient
Maintainable

with some assistance/positioning

Invasive

Intervention

oral airway, nasal trumpet, or intubation

The Basics
To assist patients in maintaining an airway: Clear mouth Position head Consider Airway adjuncts

Proper Positioning
A jaw thrust or head tilt maneuver will position the tongue so that it will not obstruct the airway Remember that a child has a relatively large tongue compared to an adult In infants it is possible to hyperextend the neck too much and cause the soft tissue to obstruct the airway

Nasal Trumpet
A nasal trumpet can be a useful adjunct
possible for the trumpet to be too long or too short

Oral Airway
An appropriately placed oral airway will pull the tongue forward and provide an unobstructed airway

If the oral airway is too long, it will stimulate a gag. If its too short, it will not lift the tongue.

Airway Adjuncts
The use of airway adjuncts, such as the nasal trumpet and oral airway, will only provide an adequate airway. The patient must have reasonable respiratory effort. If the patient is unable to maintain adequate ventilation, he/she should be bagged or proceed to endotracheal intubation.

Indications for Intubation

1. Unable to protect airway 2. Inadequate ventilation 3. Hypoxemic respiratory failure requiring positive pressure 4. Therapeutic (e.g. Hyperventilation in head injury)

Difficult Airway Considerations

Short,

muscular neck Receding mandible Protruding incisors Uvula not visualized Limited TMJ mobility Limited C-spine mobility

What do you need?

Monitors -- cardiac and pulse oximetry Suction -- Yankauer or catheter Machine -- ventilator or bag/mask Airway -- Endotracheal tube Intravenous -- peripheral or central line Drugs -sedation/analgesia/paralysis/atropine

Laryngoscopes
Straight Curved Fiberoptic

Proper visualization

The laryngoscope should be used to lift up and out. Do not rock back on upper teeth. Curved blade tip is placed in vallecula and will lift epiglottis away from airway. Straight blade tip is used to hold the epiglottis from beneath.

Proper ETT Size

Newborn - 6 months 6 months - 1 year
> 1 year

3.5 4.0

4 + age 4

Intubation Procedure
Prepare Equipment Position patient

Intubation
Laryngoscope in L hand Insert on R of mouth and sweep tongue to L Advance in midline until epiglottis visualized Advance tip of blade
into vallecula (curved blade) beneath epiglottis (straight blade)

Table height Sniffing position

Pre-oxygenate
4 max breath in 30 sec 100% O2 for 3-5 min

Induction agent
sedative/analgesic

Neuromuscular blocker

Lift towards feet

up and out, Never Lever

Rapid Sequence Intubation

Done when immediate airway stabilization is required or the patient has a full stomach has eaten -- pregnancy trauma -- abdominal mass GER -- misc bowel obstruction Expedited with rapid acting drugs and avoidance of bag mask ventilation

Rapid Sequence Intubation

Procedure Pre-oxygenate Rapid Induction Agents Rapid Acting Neuromuscular Blocker Sellicks Maneuver Intubate Check breath sounds, inflate cuff (if applicable) Release cricoid pressure

Sellicks Maneuver
Cricoid

Pressure Closes esophagus against the vertebral column protects against passive regurgitation DO NOT release until airway is secure !

Intubation Medications
Goals: Provide adequate intubation conditions
airway easily visualized patient comfort (not fighting procedure)
Avoid

complications

hemodynamic instability ICP in head injury

Atropine
Blunts

vagal response that can cause bradycardia and dries oral secretions Dose = 0.02 mg/kg (min 0.1 mg) Adverse effects
tachycardia mydriasis atropine flush disorientation

Benzodiazepines
Effective

amnesia Onset and duration vary between midazolam, lorazepam, and diazepam Dose = 0.1 mg/kg Adverse Effects include: hypotension and myocardial depression

in providing anxiolysis and

Fentanyl
Sedative/Analgesic Dose

2-5 mcg/kg Rapid Onset and short duration -- thus an excellent intubation med Virtually no CV side effects

Ketamine
PCP

Derivative, Dissociative Hypnotic Rapid Onset and short duration Dose = 1-2 mg/kg IV or 2-4 mg/kg IM Increases HR, and BP and thus may be ideal for the patient with shock. Increases cerebral metabolic rate and ICP and thus not a good choice in head injury or seizure

Thiopental (Pentothal)
Dose

= 2-5 mg/kg Max Effect in 60 seconds Sedative Hypnotic that decreases cerebral metabolic rate and ICP Hypotension and Myocardial Depression are possible adverse effects

Etomidate
Ultra

short-acting non-barbiturate hypnotic rapid induction of anesthesia with minimal cardiovascular effects 0.2-0.6 mg/kg over 30-60 seconds Peak effect: 1 minute Duration of action: 3-5 minutes Can cause adrenal suppression

Neuromuscular Blockers
Recommend

only rapid acting agents:

Succinylcholine - dose = 1 mg/kg IV Rocuronium - dose = 0.6-1.2 mg/kg IV Vecuronium - dose = 0.1-0.3 mg/kg IV Mivacurium - dose = 0.2 mg/kg IV Atracurium - dose = 0.2 mg/kg IV

Recommended Intubation Cocktails

Controlled Intubation
Fentanyl & Lorazepam or Etomidate Vecuronium/Rocuronium + Atropine Pentothal or Etomidate Lidocaine 1 mg/kg IV Vecuronium Atropine

Septic Shock
Atropine Ketamine Rocuronium/Vecuronium

Head Injury

Status Asthmaticus
Atropine Ketamine Lorazepam Rocuronium/Vecuronium

Physiologic Response to Intubation

Airway

Reflexes

Cardiovascular

Laryngospasm Cough Gag

Reflexes

Sinus bradycardia Tachycardia Hypertension Dysrhythmias

Assessing ETT placement

Direct

visualization ETCO2 (digital readout or color paper) Chest rise Auscultation (be certain to confirm absence of gastric breath sounds) ETT vapor (unreliable) Chest X-ray

Monitoring on Transport
Physical

Exam EKG monitor Pulse oximeter ETCO2 Monitor Reevaluate Frequently

Capnograms
Normal

Zero baseline Rapid, sharp up rise Alveolar plateau Well-defined end-tidal Rapid, sharp down stroke
AB BC CD D DE Deadspace Dead space and alveolar gas Mostly alveolar gas End-tidal point Inhalation of CO2 free gas

Capnography

Sudden loss of waveform

Esophageal intubation Ventilator disconnect Ventilator malfunction Obstructed / kinked ETT

Capnography

Decrease in waveform
Sudden hypotension Massive blood loss Cardiac arrest Hypothermia PE CPB

Capnography
Increased

Gradual increase in waveform

body temp Hypoventilation Partial airway obstruction Exogenous CO2 source (w/laparoscopy/CO2
inflation)

Capnography
Leak

Sudden drop not to zero

in system Partial disconnect of system Partial airway obstruction ETT in hypopharynx

Capnography
Asthma PE Pneumonia

40 30

Sustained low EtCO2

Hypovolemia Hyperventilation

Low ETCO2, but good plateau

Capnography
Partial

Cleft in alveolar plateau

recovery from neuromuscular blockade
40

Capnography

Transient rise in ETCO2

Injection

of bicarbonate Release of limb tourniquet

40

Capnography

Sudden rise in baseline

Contamination

of the optical bench need to recalibrate

40

Questions
1.

Which drug is not used in the intubation of a head injury patient?

A. Ketamine B. Thiopental C. Lidocaine D. Etomidate

Question

2.Capnograph represents

A. Esophageal intubation B. Ventilator disconnect C. Obstructed / kinked ETT D. All of the above

Question
3.

Appropriate ETT size for a 6 year old calculated by formula is?

A. 6.0 B. 4.5 C. 5.0 D. 5.5

Question
4.

True or False:

Curved blade tip is placed in vallecula and will lift epiglottis away from airway

Question
5.

All of the following are indications for intubation except:

A. Unable to protect airway B. Inadequate ventilation C. Hypoxemic respiratory failure requiring positive pressure D. GCS 10